Enrolment/Emergency Form

Whitney Child Centre Enrolment/Emergency Form
Student Surname
Student Name
Date of Admission

DD
MM
YYYY
Male Female (Please circle)
Date of Birth

DD
MM
YYYY
Home Address
Postal Code
Home Phone
Email Address
Parent 1 Information
Home address as above or:
Parent/Guardian Name
Home Address, as above or:
Postal Code
Home Phone
Cell Phone
Business Phone
Email Address
Parent 2 Information
Home address as above or:
Parent/Guardian Name
Home Address
Postal Code
Home Phone
Cell Phone
Business Phone
Email Address
Business Address for one parent
Postal Code
Parent 3 Information
Home address as above or:
Parent/Guardian Name
Home Address, as above or
Home Phone
Cell Phone
Business Phone
Email Address
Parent 4 Information
Home address as above or:
Home Address, as above or
Home Phone
Cell Phone
Untitled
Business Phone
Email Address
Business Address
Please indicate which parent (1,2,3,4)
Business Address
Postal Code
Phone
Child's Name
Emergency Contact 1
Other than parent/guardian
Name
Relationship
Address including Postal Code
Home Phone
Bus/Cell Phone
Emergency Contact 2
Other than parent/guardian
Name
Relationship
Address including Postal Code
Home Phone
Bus/Cell Phone
Doctor Information
Name of Doctor
Doctor's Address
Postal Code
Phone
Date of last tetanus shot (DPTP)

DD
MM
YYYY
Drug Allergies
Food/Other Allergies
Does your child have anaphylactic symptoms? What symptoms do you see if your child is exposed to allergen?
Dietary Restrictions
Any medical conditions
Other than parents, people authorized to pick up your child
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone
Parent Signature
Name
Date

DD
MM
YYYY

Whitney Child Centre Enrolment/Emergency Form

Parent 1 Information

Parent 2 Information

Parent 3 Information

Parent 4 Information

Business Address

Emergency Contact 1

Emergency Contact 2

Doctor Information

Other than parents, people authorized to pick up your child

Parent Signature